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K-- l UNIFIED PROGRAM(UP)FORM UNDERGROUND STORAGE TANKS-TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all that apply) Page of J UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 0 t.PRESSURE ❑2.SUCTION 03.GRAVITY 45a ❑1.PRESSURE ❑2. SUCTION ❑3.GRAVITY 4S9 ` CONSTRUCTION 0 1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 0 1.SINGLE WALL ❑95.UNKNOWN 462 J MANUFACTURER®2.DOUBLE WALL ❑95_UNKNOWN [12.DOUBLE WALL ❑99.OTHER MANUFACTURER To1a1 CwAainmerat OmnlFlexll 461 MANUFACTURER 463 MATERIALS AND ❑1.BARE STEEL ❑6.FRP COMPATIBLE wl100% CORROSION METHANOL 01.BARE STEEL ❑6.FRP COMPATIBLE Wil W%METHANOL PROTECTION ❑95.UNKNOWN E)2.STAINLESS STEEL ❑7.GALVANIZED STEEL (32.STAINLESS STEEL [17.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WI CONTENTS 0 8.FLEXIBLE(HDPE) ❑3.PLASTIC COMPATIBLE WICONTENTS ❑E FLEIBBLE(HDPE)❑95.UNKNOWN ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL WICOATING ❑99.OTHER 464 1 ❑5.STEEL WICOATING ❑99. OTHER 465 VII.PIPING LEAK DETECTION(check all that a")(Adeavipion offtn"gkirIng pngrarn small besemiaed aoare local enc.) N UNDERGROUND PIPING ABOVEGROUND PIPING CL- SINGLE WALL PIPING aha SINGLE WALL PIPING 467 M PRESSURIZED PIPING(Check as that apply): PRESSURIZED PIPING{Check all that eppfy}: C13 co ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM SHUT OFF FOR LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. DISCONNECTION+AUDIBLE AND VISUAL ALARMS. N ❑2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(DAGPH) ❑3.ANNUAL INTEGRITY TEST(O.1GPH) [14. DAILY VISUAL CHECK o CONVENTIONAL SUCTION SYSTEMS(Cheek at that appy) CONVENTIONAL SUCTION SYSTEMS(Check ar that appy} ❑5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING LID INTEGRITY TEST(0.1 GPH) ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM v c ❑6. TRIENNIAL IN7EGRrrY TEST(0.1 GPH) N SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPWGk SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): c i ❑7.SELF MONITORING ❑7, SELF MONITORING i GRAVITY FLOW GRAVITY FLOW[Check as that apply) ❑9.BIENNIAL INTEGRr1Y TEST(D.1 GPH) 06.DAILY VISUAL MONITORING 09.BIENNIAL INTEGRITY TEST(0.1 GPH) N SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING ca PRESSURIZED PIPING(Check M that apply): PRESSURIZED PIPWG IChedk all shat appyy 0 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 1D. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL N ALARMS AND(Check one) ALARMS AND(Check one) 00 \ ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS N \` ®It. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND ❑6 AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM z SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF 0C NO AUTO PUMP SHUT OFF d 0 11. AUTOMATIC LEAK DETECTOR(3.0 GPH TEST)WITHFLOW SHUT OFF ❑11. AUTOMATIC LEAK DETECTOR ❑42. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRrTY TEST(0.1 GPH) SUCTIONtGRAVITY SYSTEM SUCTIOWGRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY{Check as Ghat appy) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR Wffl-IOUT AUTO PUMP SHUT OFF0 14. CONTINUOUS SUMP S ENSOR WrrHOUTAUTO PUMP SH Ur OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LEAK DETECTOR(3.0 GPH)W4TN FLOW SHUT OFF E)15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK 0 16.ANNUAL INTEGRITY TEST(11A GPH) ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 41iB ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑S.TRENCH LINER I MONITORING 1997 C9 3.CONTINUOUS DISPENSER PAN SENSOR VM AUTO SHUTOFF FOR ❑6.NONE 465 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I cerirly that the iM0rnu6on PvAded heron is true and acrasabe so Ilte best d try knowledge. SIGNATURE OF OWNERIOPERA DATE (p 2 7 a 6 470 I NAME OF OWNEWPRA OR(p-0M) TITLE OF OWNEWOPERATOR 472 Mike Eliasorl Cardlock Manager OFFICIAL USE ONLY Permit Number d73 Permit Approved 474 Permit Expiration Date 475 UP FORM(112400 Version) 3 Formerly SVVRCB Form B U SBC UST-B.doc n r